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Limited Cutaneous Cryptococcosis — SCE Infectious Diseases MCQ

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ModerateFungal InfectionsLimited Cutaneous CryptococcosisSCE Infectious Diseases

A 30-year-old man with HIV (CD4 600, VL <50) develops a solitary subcutaneous nodule on his arm. Biopsy shows encapsulated yeast with a thick polysaccharide capsule visible on India ink stain. Serum CrAg is positive at 1:16. LP is normal. What treatment is appropriate for this limited cutaneous cryptococcosis?

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Correct answer: A — Fluconazole 400 mg daily for 6–12 months — limited cutaneous/soft tissue cryptococcosis without meningitis can be treated with Fluconazole consolidation-dose without Amphotericin B induction

This biopsy and India ink appearance identify Cryptococcus. Cutaneous cryptococcosis is never simply observed because skin disease may reflect dissemination, so evaluation for CNS disease is essential. Here, the patient has well-controlled HIV, a solitary limited cutaneous/subcutaneous lesion, low-titre serum CrAg, and a normal LP, so cryptococcal meningitis is excluded. For limited non-CNS disease without severe pulmonary disease, cryptococcaemia or meningitis, the appropriate exam answer is oral fluconazole 400 mg once daily for a prolonged course, typically 6–12 months. Liposomal amphotericin B plus flucytosine is reserved for cryptococcal meningitis, cryptococcaemia/disseminated disease or severe disease. Caspofungin is ineffective against Cryptococcus, and itraconazole is not first-line when fluconazole can be used.

Reference: Infectious Diseases Society of America (IDSA). Clinical Practice Guidelines for the Management of Cryptococcal Disease: 2010 Update; current IDSA online guideline. https://academic.oup.com/cid/article/50/3/291/392360